Identity Theft Complaint Form - Missouri Attorney General
Identity Theft Complaint Form - Missouri Attorney General
Identity Theft Complaint Form - Missouri Attorney General
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<strong>Identity</strong> <strong>Theft</strong><br />
<strong>Complaint</strong> <strong>Form</strong><br />
<strong>Missouri</strong> <strong>Attorney</strong> <strong>General</strong><br />
Chris Koster<br />
RETURN TO:<br />
<strong>Attorney</strong> <strong>General</strong>’s Office<br />
Consumer Protection Unit, PO Box 899<br />
Jefferson City, MO 65102<br />
Phone: 800-392-8222<br />
Web: ago.mo.gov<br />
DATE THIS FORM WAS FILLED OUT (MM DD YY)<br />
MONTH DAY YEAR<br />
YOUR NAME<br />
MR.<br />
MRS.<br />
MS.<br />
FIRST<br />
MIDDLE<br />
LAST<br />
HOME ADDRESS<br />
STREET CITY STATE ZIP<br />
HOME<br />
PHONE ( ) CELL<br />
( ) WORK<br />
PHONE<br />
PHONE<br />
( )<br />
E-MAIL<br />
1. How did you become aware of the identity crime?<br />
Found fraudulent charges on my credit card bill. Which one?<br />
Found fraudulent charges on my cellular phone bill. Which one?<br />
Received bills for an account(s) I did not open. Which one?<br />
Found irregularities on my credit report.<br />
Was contacted by a creditor demanding payment. Which one?<br />
Was contacted by a bank’s fraud department about charges. Which one?<br />
Was denied a loan.<br />
Was denied credit.<br />
Was arrested, had a warrant issued, or a complaint<br />
filed in my name for a crime I did not commit. In what city or county?<br />
Was sued for a debt I did not incur. Which one?<br />
Was not regularly receiving bills<br />
for a legitimate account. Which one?<br />
Was denied employment.<br />
Had my driver’s license suspended for actions I did not commit.<br />
Received notice of a legal action I did not file, such as a bankruptcy.<br />
Other:<br />
REVISED JANUARY 2009
PAGE 2<br />
<strong>Identity</strong> <strong>Theft</strong> <strong>Complaint</strong> <strong>Form</strong><br />
<strong>Missouri</strong> <strong>Attorney</strong> <strong>General</strong>’s Office<br />
2. What date did you first<br />
become aware of the identity crime?<br />
(MM DD YY) MONTH DAY YEAR<br />
3. When did the<br />
fraudulent activity begin?<br />
4. What is the full name, address and other identifying information that the fraudulent activity was made under?<br />
NAME<br />
FIRST<br />
MIDDLE<br />
LAST<br />
ADDRESS<br />
STREET CITY STATE ZIP<br />
5. Please list all fraudulent activity that you are aware of to date, with the locations and addresses of where fraudulent<br />
applications or purchases were made (retailers, banks, etc.). List in chronological order, if possible. For example:<br />
"On 9-18-02, I received a letter from MM Collections, stating that I had accumulated $5,000 worth of charges on American<br />
Express Account 123456789. On 9-18-02, I called American Express and spoke with Jennifer Martin. She said the account<br />
was opened on 5-12-02 by telephone. I did not open this account, even though it was in my name. The account address was<br />
123 Main St., Anytown, NE. Ms. Martin said she would send me an Affidavit of Forgery to complete and return to her."<br />
Please be concise and state the facts. You may attach a separate sheet of paper if you need more space.
PAGE 3<br />
<strong>Identity</strong> <strong>Theft</strong> <strong>Complaint</strong> <strong>Form</strong><br />
<strong>Missouri</strong> <strong>Attorney</strong> <strong>General</strong>’s Office<br />
6. To the best of your knowledge at this point, what identity crimes have been committed?<br />
Making purchase(s) using my credit cards or credit card numbers without authorization.<br />
Opening new credit card accounts in my name.<br />
Opening utility and/or telephone accounts in my name.<br />
Unauthorized withdrawals from my bank accounts.<br />
Opening new bank accounts in my name.<br />
Taking out unauthorized loans in my name.<br />
Unauthorized access to my securities or investment accounts.<br />
Obtaining government benefits in my name.<br />
Obtaining employment in my name.<br />
Obtaining medical services or insurance in my name.<br />
Evading prosecution for crimes committed by using my name or committing new crimes under my name.<br />
Check fraud.<br />
Passport/visa fraud.<br />
Other:<br />
7. Do you have any information on a suspect in this identity crime case? If so, please provide as much information as<br />
possible about the suspect, including the suspect’s full name, phone number and address. How do you believe the<br />
identity crime occurred?<br />
SUSPECT’S<br />
NAME<br />
FIRST<br />
MIDDLE<br />
LAST<br />
PHONE<br />
( )<br />
ADDRESS<br />
STREET CITY STATE ZIP
PAGE 4<br />
<strong>Identity</strong> <strong>Theft</strong> <strong>Complaint</strong> <strong>Form</strong><br />
<strong>Missouri</strong> <strong>Attorney</strong> <strong>General</strong>’s Office<br />
8. Please list any government documents fraudulently obtained in your name (driver’s licenses, Social Security cards, etc.)<br />
9. Have you contacted the following organizations and requested a Fraud Alert be put on your account?<br />
(Check all that you have contacted about a Fraud Alert.)<br />
Equifax.<br />
TransUnion.<br />
Experian.<br />
What date? What date? What date? MM DD YY MM DD YY<br />
MM DD YY<br />
Your bank(s). Names of bank(s):<br />
Department of Motor Vehicles.<br />
Social Security Administration.<br />
Other:<br />
10. Have you requested a credit report from each of the three credit bureaus?<br />
(Check all that you have requested a credit report from.)<br />
Equifax TransUnion Experian If you have any reports, please attach a copy of each to this form.<br />
Please keep your original documents in a safe place. Send<br />
ONLY COPIES to the <strong>Attorney</strong> <strong>General</strong>’s Office at this time.<br />
BY FILING THIS COMPLAINT, I UNDERSTAND THAT:<br />
The <strong>Attorney</strong> <strong>General</strong> is not my private attorney, but enforces state consumer protection laws and I will testify in court<br />
to the facts stated in this complaint.<br />
I ATTEST TO THE ACCURACY OF STATEMENTS MADE IN THIS COMPLAINT:<br />
YOUR SIGNATURE<br />
DATE